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SPARKS ESSAY SUBMISSION 1
Expedited ‘Diffusion of Innovation’: A reflection on the Ponseti Method in the
current era of medicine
Asitha Jayawardena
4/30/12
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Expedited ‘Diffusion of Innovation’: A reflection on the Ponseti Method in the
current era of medicine
Basic physical fitness has been a prerequisite for survival since the early
evolution of man. Despite technological and societal advances that currently allow
humans to succeed without basic physical function1, those who are not able to
function at levels similar to the rest of society are labeled ‘disabled.’ Developed
countries such as the United States attempt to accommodate for disability. 2 We
have laws that ensure the construction of handicap-accessible buildings, motorized
wheelchairs that enhance mobility, and other accommodations that allow the
physically disabled to function more normally within our society. 2
Unfortunately, the same cannot always be said about the developing world. 2
These regions of the globe often rely more heavily on physical labor to make a living.
Therefore, the physically disabled are unable to contribute to society as they might
have if they lived in a resource-rich county. In fact, many of the physically disabled
are relegated to a life as ‘beggars.’ 3
Advances in medicine in the past few hundred years have been profound.
The disease burden has been shifted from infectious disease to chronic disease – a
trend so successful that we have eradicated diseases such as smallpox completely. 4,5
Other examples of our success include the near eradication of polio; a disease that
previously left affected survivors in a state of profound physical disability. 6
However, our battle against physical disability is not over. In fact, the most common
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congenital musculoskeletal disorder that leads to disability worldwide is a condition
that is found most often in the developing world. 7,8
That disorder is called tilapes equinovarus, but is more commonly referred
to as clubfoot. 8 At least some aspect of the disease transmission is hereditary,
although the exact pathogenesis remains unknown. 10 The disorder is found in 1-
8/1000 newborns9 and is characterized by an inward and downward positioning of
the foot that makes it impossible to walk with a physiologic gait when it is left
untreated. 10,11 Untreated clubfoot is not only very painful, but often results in social
neglect and life as a beggar. 11,13 Some cultures even believe that clubfoot is a curse
from the Gods and choose to pursue witchdoctor/voodoo medicine versus typical
Western healing. 12,13
History of Clubfoot Treatment:
Historical documentation of clubfoot occurred as early as 1000 B.C. where
the deformity was first depicted in ancient Egyptian tomb paintings. 14 In fact,
posthumous radiographic evidence suggests that the famous Egyptian pharaoh
Tutankhamen and several members of his family were burdened with untreated
clubfoot. 15 Later documentation of clubfoot occurs in 400 B.C. when the father of
Western medicine himself, Hippocrates, describes clubfoot and clubfoot treatment.
14,16,17,18 Hippocrates, whose writings and thoughts on the field of medicine have
withstood the test of time, is not commonly known for his writings on clubfoot. 18
Hippocrates, however, describes various important principles in the management of
clubfoot that 2400 years later remain important aspects of the current treatment
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guidelines. 15,16,17 Hippocrates emphasized that early treatment was paramount to
success. 14 He also suggested serial manipulations using bandages that result in
overcorrection, followed by bracing was a preferred treatment. 14 Unfortunately, the
treatment Hippocrates documented was soon disregarded by his predecessors. 14
Various alternate treatments emerged throughout the Middle Ages. 14 The
details of treatment of clubfoot in the middle ages are not currently understood. 14
However, it has been documented that barber-surgeons, charlatans, and bonesetters
were the professions responsible for clubfoot treatment. 14
In 1658, the famous Spanish surgeon Arcaeus documented treatment that
included stretching and the use of two mechanical devices to maintain correction. 14
In the 1700s, a similar stretching technique was documented. 14 In 1803, the Italian
anatomist Scarpa documented a technique including forceful manipulation and the
use of a complicated device as treatment for clubfoot. 14,19 Dr. Timothy Sheldrake, a
British physician, documented the use of bandages similar to those used by
Hippocrates in his treatment of clubfoot in 1806. 14
In 1823, the French surgeon Delpech recorded the first subcutaneous
tenotomy of the Achilles tendon, albeit to unfortunately poor results. 14 However,
the German surgeon Louis Stromeyer continued to practice the subcutaneous
tenotomy in 183119 and eventually taught the practice to a young British surgeon W.
J. Little, who perfected the technique to much success. 14,17,20 The method arrived in
the US in 1834 and 1835 due to the work of Drs. Rogers and Dixon. 14 In 1838, one of
the most celebrated orthopaedists in Europe, Dr. M. Jules Guerin first demonstrated
the use of plaster of paris in the treatment of clubfoot. 14 In the 1860s, advanced
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surgical techniques allowed for the use of complex surgeries to attempt to correct
the anatomical deformities associated with clubfoot. 14 In 1939, John Hopkins
surgeon Dr. Joseph Kite published his non-surgical method to treat clubfoot. His
method soon became the standard of care within the orthopaedic community. 16
However, as it is understood today, the principles of Kite’s method were not
sound, leading to alterations in its practice and surgical additions resulting in most
cases being treated by extensive surgery. 16 Clubfoot centers around the world
began publishing and presenting on alterations to the surgical technique to achieve
‘better’ results. 16 Unique surgical procedures for clubfoot were published by a
number of different physicians including: Dr. Dilwyn Evans, Dr. Vincent Turco, Dr.
Leonard Goldner, Dr. Douglas McKay, Dr. George Simons, Dr. George Lloyd-Roberts,
Dr. Anthony Catterall, Dr. G Imhauser, Dr. Henri Bensahel, Dr. Sherman Coleman, Dr.
Alain Dimeglio, Dr. John Roberts, Dr. Arthur Steindler and Dr. Norris Carroll. 16 The
novelty of surgery and the tendency of orthopaedic surgeons to favor surgery
allowed surgical treatment of clubfoot to be the preferred method of treatment until
the past 15 years. 14 However, in parallel to the surge in publications about surgical
treatments in clubfoot, Dr. Ignacio Ponseti at the University of Iowa was perfecting a
non-surgical method of his own.
Dr. Ponseti began work on what would soon become the Ponseti method in
the 1940s after Dr. Arthur Steindler of the University of Iowa asked Dr. Ponseti to
review the technique Steindler had created16. Dr. Ponseti concluded the technique
was unsatisfactory and left children with stiff ankles and a compromised gait. 16
Ponseti understood what others had failed to understand – that ‘calcaneal internal
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rotation (adduction) and plantar flexion are the key deformity.’ 16 He developed a
specific non-surgical manipulation technique that required up to 5 weeks in plaster
of paris casts followed by the use of a foot-abduction brace during the child’s sleep
for 4 years. 10 The 5-6 casts are a progressive treatment that corrects all deformities
of clubfoot simultaneously. 10 The foot abduction brace is an essential component for
preventing painful and debilitating clubfoot relapse. 9 To complete the correction, a
percutaneous tenotomy is performed to lengthen the Achilles tendon. 10 This
procedure can be completed in an outpatient setting with local anesthesia. 10
Despite publishing his specific method of serial casting and percutaneous
tenotomy to treat clubfoot in the 1960s, Dr. Ponseti’s method did not gain
popularity amongst the orthopaedic community until recently. 14,16,21 However,
despite its late dissemination, today the Ponseti method is considered the standard
of care for clubfoot treatment throughout the world. Studies have shown the
method to be over 95% effective when administered correctly. 8,9,10,14,16 The low
cost, highly efficient Ponseti method is especially important in developing countries,
where the majority of clubfoot occurs, because of their lack of capital to pursue
highly complex surgical treatments. 7,9,11,13
Diffusion of Innovation:
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Everett Rogers first described the ‘Diffusion of Innovation’ theory in 1962. 22
Rogers was a rural sociologist at Iowa State University who grew up on his father’s
rural farm. 23 He developed the ‘Diffusion of Innovation’ theory after watching his
father fail to adopt the best-practice farming techniques of his time. 23 His model
outlines the adoption of any innovation until it is accepted as commonplace amongst
a society. 23
Initially, only the innovator uses an innovation. 23 The innovation is
eventually spread to early adopters, who are characterized by their willingness to
try new things. This group makes up 13.5% of society. 23 Next, the early majority will
accept the innovation. The early majority represents 34% of society and adopts the
innovation only after having observed others’ success. 23 The late majority tends to
be more conservative in their approach and adopts only after observing the early
majorities continued success. They make up 34% of society. Finally, the laggards are
those who refuse to adopt until they have no other option. This often occurs when
the previous product (i.e. VCRs) is no longer being sold because the industry
standard has shifted (ie. DVD/Blu-ray). Laggards represent 16% of society. 23
Rogers suggests that various factors influence an innovation’s diffusion
throughout these groups23. The factors, which describe the innovation, include:
relative advantage, compatibility, complexity, trialability, and observability. 23 An
individual carefully weighs these factors when deciding to utilize a particular
innovation. 23 Other factors that influence an innovation’s diffusion include the
social context of the innovation and the communication channels used for
dissemination. 23
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The Clinical context of Diffusion theory:
The decision-making process an individual undergoes when accepting an
innovation in a clinical setting is described by RW Sanson-Fisher. 24 First, knowledge
must be attained by researchers regarding the clinical change. 24 In the context of
the Ponseti method, this was initially completed by Dr. Ignacio Ponseti and his
colleagues at the University of Iowa. The individual physician then must be
persuaded by the advantages of the innovation over their current practice. 24 The
clinician then independently engages in activities that help them choose to reject or
accept the new practice. 24 These activities may include attending conferences,
conversing with ‘expert’ colleagues in the field, and reading medical journals. 24 The
innovation must then be incorporated into the daily activities of the physician. 24
Once this innovation is incorporated, the clinician then seeks reinforcement from
their peers and results justifying their acceptance of the innovation. 24
The hierarchal nature of the field of medicine may hinder effective diffusion.
24 Despite being a field of constant innovation, the tendencies of our mentors are
inevitably passed on to our students. Despite an effective trend towards enhancing
evidence-based medicine, a gap exists between evidence-based practice and current
care. This gap has previously been characterized as the Knowledge Gap. 25
Relative Advantage:
Innovation in the field of medicine is passed through rigorous scrutiny
regarding its relative advantage over previous techniques. Easy-to-access online
medical databases with up-to-date medical literature such as Pubmed,
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Uptodate.com, and others allow physicians to access recent evidence-based
medicine techniques. 26,27 Strict peer-reviewed publication guidelines establish a
necessary statistically significant difference to be demonstrated in treatment
results.
Exactly 244 studies populate a Pubmed search for ‘Ponseti method.’ 26 Most
all of these studies agree that the Ponseti method is the gold standard treatment for
clubfoot, with an over 95% treatment success. 9 The previous surgical treatment for
clubfoot has been documented with over a 50% relapse rate. The relative advantage
of the Ponseti method is made remarkably clear in the field of medicine by access to
peer-reviewed journal articles.
Physicians, however, might be hindered in their perspective of the
innovation if they observe physicians claiming to be practicing the true Ponseti
method, but are practicing a method with inadequate technique. Observing the
limited success of these substandard manipulations might negatively influence one’s
perception on the Ponseti method.
Compatibility:
The Ponseti method, especially when first proposed, provided a clear
contrast to the previous treatment standard of surgery. Surgery has been especially
popular with orthopaedic surgeons, the specialist of choice for clubfoot patients, for
multiple reasons. 16 Surgeons, who have spent decades training about the art and
complexity of surgery, exhibit a certain bias towards surgical methods of treatment
versus non-surgical methods. Additionally, surgeons are trained in a culture that
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favors short immediate fixes. The Ponseti method is a patient method that requires
at least 5-7 weeks of casting and up to 4-5 years in a foot abduction brace.
Most groundbreaking innovations in the current era of medicine involve
technological advances such as nuclear imaging, use of stem cells, etc. The Ponseti
method of a simple casting and bracing technique was not compatible with the
medical innovation orthopaedic surgeons have grown accustomed to. In fact, the
Ponseti method may reminds surgeons of the very first treatments of clubfoot
described by Hippocrates himself over 2400 years ago. 14,16,18 The ‘compatibility’ of
non-surgical treatment in the circles of orthopaedic surgeons may play a role in
hindering clubfoot’s dissemination throughout the orthopaedic social sphere.
Complexity:
Although the Ponseti method is a complex maneuver that requires
experienced hands to achieve the most successful manipulation, it is not a technique
that many in the orthopaedic world would consider remarkably difficult. In fact,
many have described the method as one that non-orthopaedic specialists can
perform. This flexibility in administration makes the method especially useful in the
developing world. 28 However, the perceived simplicity of the method might hinder
surgical perceptions on effectiveness.
Trialability:
Another remarkable feature in the Ponseti Method’s diffusion is its
trialability. Practitioners can learn the basic method themselves in a weekend long
workshop administered by the Ponseti International Association from the
University of Iowa. Additionally, the method is one that can be taught from
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practitioner to practitioner. The ease of use when it comes to trying the method is
favorable to its dissemination.
Observability:
Clubfoot and the Ponseti method are assisted in their diffusion by some
remarkably observable results. 10 Clubfoot is an easily distinguishable deformity
that is characterized by a midfoot cavus, forefoot adductus, hindfoot varus, and
hindfoot equinus. 10 The widespread extent of clubfoot throughout the world as well
as its characteristic appearance have led to many different names for the deformity
within each culture. Parents and physicians can easily observe the characteristic
clubfoot deformity return to a physiologically normal looking foot within weeks. 29
The easily observable correction with each applied cast helps practitioners observe
the utility of the method.
Communication Channels:
In addition to characterizing the factors of an innovation, one must also
understand the communication channels in which the innovation is presented. In
fact, communication channels are one of the most important elements in an
innovation’s dissemination speed. 23,24 Communication channels can include both
micro-level communication and macro-level communication. Micro-level
communication includes face-to-face interactions between like-minded people.
Macro-level communication includes mass media campaigns including television,
radio, and billboards.
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Medically, innovations are often initially published in medical journals. 24 The
higher rank and viewership of the medical journal results in expedited diffusion.
Additionally, face-to-face communication occurs at medical conferences. 16,24
Specialty-specific medical conferences offer physicians to not only speak with the
innovator themselves, but also with their medical peers who are similarly weighing
whether or not to utilize a particular innovation within their own practice. 24
The Ponseti method underwent a unique dissemination within the field of
medicine. Despite documenting his success in the medical literature the method was
not widely disseminated until an additional communication channel was
introduced. In the 1990’s, the use of the Internet amongst parents of children with
clubfoot jumpstarted the demand for the Ponseti Method at the University of Iowa.
21 Five large support groups with a total of 30000 messages were the primary
communication channel for parents wishing to share either their treatment success
with the method or their frustration with surgical treatment. 21 After the University
of Iowa Hospitals and Clinics posted a virtual hospital webpage on the Internet
about their Ponseti care, they received a drastic increase in patients from previous
years. 21 Morcuende, Egbert, and Ponseti reported 790,084 hits to the virtual
hospital web pages. 21 The University received requests for information from all 50
states and 72 different countries. 21 The Internet and clubfoot support groups were a
major communication channel to spread the Ponseti method amongst physicians.
Physicians were soon introduced to a new communication channel – parents
requesting information about the Ponseti method. 21 After this surge of popularity in
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the 1990s, Dr. Ponseti and the University of Iowa began educating physicians who
wished to become familiar with the Ponseti method.
Strategic Implementation of Diffusion Theory Eradicate Neglected Clubfoot:
Traditionally, physician education on the Ponseti method has been
administered through weekend long hands-on workshops in which Ponseti experts
travel to areas of the world bereft in Ponseti care and teach local practitioners how
to utilize the method. While this method was initially successful, careful analysis of
Everett Rogers’ Diffusion of Innovation Theory suggests an alternate education
method.
Rogers describes heterophily and homophily as important aspects in
communication channels when it comes to dissemination. 23 Heterophily is
described by Rogers as, ‘the degree to which pairs of individuals who interact are
similar in certain attributes, such as beliefs, education, social status, and the like.’ 23.
Homophiles are very effective communicators because of their similarities in
behavior, attitude, and knowledge. 23 However, complete homophily is detrimental
to initiating change because the two participants are so alike, no information can be
exchanged. 23 Unfortunately, the previous method to spread the Ponseti method
resulted in heterophiles, the opposite of homophiles, spreading information about
the innovation. The differences in language, interests, healthcare systems,
socioeconomic status, etc. resulted in inadequate diffusion. The ideal situation
would be two near-complete homophiles, alike in every way except for knowledge
of the innovation, to interact in order to spread the method.
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The new strategy in the diffusion of the Ponseti method utilizes this theory-
based concept. The Ponseti International Association with support from a Ronald
McDonald House grant and funds raised by the American Medical Student
Association Iowa chapter are utilizing a ‘fellowship’ system that brings individual
physicians from areas of the world in Ponseti need to the University of Iowa to
master the Ponseti method from the Department of Orthopaedics, Dr. Ponseti’s
former department. These physicians will then return to their country as
homophiles, however, with a thorough knowledge of how to both use the Ponseti
method as well as teach it to their peers.
To best enhance diffusion, Rogers suggests targeting ‘change agents.’ 23
Change agents, or opinion leaders, are very influential (positive and negative) in the
diffusion of an innovation. 23 Change agents are typically more innovative,
charismatic, have many social contacts, have a high socioeconomic status, and have
much social experience and exposure. 23 By targeting these change agents as
fellowship participants, we can use our knowledge of Rogers’ Diffusion of
Innovation Theory to expedite the spread of Dr. Ponseti’s best-practice method to
treat clubfoot.
The fellowship model may be the most cost-effective way to ensure physician
understanding of the Ponseti method throughout the world. Worldwide physician
education on the Ponseti method is certainly the best way to eradicate neglected
clubfoot and the resulting physical disability. Strategic implementation of the
‘Diffusion of Innovation theory’ will be instrumental in achieving this goal.
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